Esophageal and paraesophageal varices are abnormally dilated veins of the esophagus. They are native veins that serve as collaterals to the central venous circulation when flow through the portal venous system or superior vena cava (SVC) is obstructed. Esophageal varices are collateral veins within the wall of the esophagus that project directly into the lumen. The veins are of clinical concern because they are prone to hemorrhage. Paraesophageal varices are collateral veins beyond the adventitial surface of the esophagus that parallel intramural esophageal veins. Paraesophageal varices are less prone to hemorrhage. Esophageal and paraesophageal varices are slightly different in venous origin, but they are usually found together.
Esophageal and paraesophageal varices are displayed in the images below.
Uphill esophageal varices. Barium swallow demonstrates multiple serpiginous filling defects primarily involving the lower one third of the esophagus with striking prominence around the gastroesophageal junction. The patient had cirrhosis secondary to alcohol abuse.
Downhill esophageal varices on barium swallow examination. Notice the serpiginous filling defects proximally with normal-appearing esophagus distally.
Computed tomography scan shows large, enhancing paraesophageal varices just to the left of the esophagus. Note the ascites and cirrhosis.
Maximum intensity projection magnetic resonance image of the portal venous system demonstrates extensive esophageal varices (arrows) in conjunction with splenic and gastric varices. L = liver. Courtesy of Ali Shirkhoda, MD, William Beaumont Hospital, Royal Oak, Mich.
Using a thin-barium technique, radiographic appearances of esophageal varices were described first by Wolf in his 1928 paper, “Die Erkennug von osophagus varizen im rontgenbilde,” or “Radiographic detection of esophageal varices.”
In 1931, Schatzki established the basis for the modern-day fluoroscopic detection of esophageal varices by refining positional and physiologic maneuvers to optimize visualization.
Today, more sophisticated imaging with computed tomography (CT) scanning, magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), and endoscopic ultrasonography (EUS) plays an important role in the evaluation of portal hypertension and esophageal varices.
Endoscopy is the criterion standard for evaluating esophageal varices and assessing the bleeding risk.
This procedure is performed by a surgeon or a gastroenterologist with the patient under light sedation. The procedure involves using a flexible endoscope inserted into the patient’s mouth and through the esophagus to inspect the mucosal surface.
An endoscopic image of esophageal varices. Courtesy of Dr M Inayatullah, Professor of Medicine, Nishtar Hospital, Multan, Pakistan.
Endoscopic picture of esophageal varices. Courtesy of Dr M Inayatullah, Professor of Medicine, Nishtar Hospital, Multan, Pakistan.
Endoscopic pictures of esophageal varices. Courtesy of Dr M Inayatullah, Professor of Medicine, Nishtar Hospital, Multan, Pakistan.
When esophageal varices are discovered, they are graded according to their size, as follows:
Grade 1 – Small, straight esophageal varices
Grade 2 – Enlarged, tortuous esophageal varices occupying less than one third of the lumen
Grade 3 – Large, coil-shaped esophageal varices occupying more than one third of the lumen
The esophageal varices are also inspected for red wheals, which are dilated intra-epithelial veins under tension and which carry a significant risk for bleeding. The grading of esophageal varices and identification of red wheals by endoscopy predict a patient’s bleeding risk, on which treatment is based.
Esophageal varices with cherry red spots. These spots are suggestive of recent or impending bleeding from the varices. Courtesy of Dr M Inayatullah, Professor of Medicine, Nishtar Hospital, Multan, Pakistan.
Varices can also be seen in the stomach and the duodenum.
Fundal varices found during endoscopic examination of the stomach. Courtesy of Dr M Inayatullah, Professor of Medicine, Nishtar Hospital, Multan, Pakistan.
Fundal varices seen on endoscopic examination of the stomach. Courtesy of Dr M Inayatullah, Professor of Medicine, Nishtar Hospital, Multan, Pakistan.
Fundal varices. The photo on the right shows endoscopic findings in a 47-year-old man with a history of polycythemia rubra vera who had a recent episode of hematemesis. Endoscopy showed a normal esophagus, but multiple polypoid submucosal lesions were seen in the fundus and body of the stomach. The final diagnosis was left-sided portal hypertension secondary to splenic vein thrombosis.
Duodenal varice noted on endoscopic exam. Courtesy of Dr M Inayatullah, Professor of Medicine, Nishtar Hospital, Multan, Pakistan.
Endoscopy is also used for interventions. The following pictures demonstrate band ligation of esophageal varices.
These two photos show band ligation of esophageal varices. The image on the right is of a 43-year-old patient with known alcoholic cirrhosis and portal hypertension presented with a massive hematemesis. The bleeding esophageal varices were banded during the endoscopic procedure.
CT scanning and MRI are identical in their usefulness in diagnosing and evaluating the extent of esophageal varices. These modalities have an advantage over endoscopy because CT scanning and MRI can help in evaluating the surrounding anatomic structures, both above and below the diaphragm. CT scanning and MRI are also valuable in evaluating the liver and the entire portal circulation.
These modalities are used in preparation for a transjugular intrahepatic portosystemic shunt (TIPS) procedure or liver transplantation and in evaluating for a specific etiology of esophageal varices. These modalities also have an advantage over both endoscopy and angiography because they are noninvasive. CT scanning and MRI do not have strict criteria for evaluating the bleeding risk, and they are not as sensitive or specific as endoscopy. CT scanning and MRI may be used as alternative methods in making the diagnosis if endoscopy is contraindicated (eg, in patients with a recent myocardial infarction or any contraindication to sedation).
In the past, angiography was considered the criterion standard for evaluation of the portal venous system. However, current CT scanning and MRI procedures have become equally sensitive and specific in the detection of esophageal varices and other abnormalities of the portal venous system. Although the surrounding anatomy cannot be evaluated the way they can be with CT scanning or MRI, angiography is advantageous because its use may be therapeutic as well as diagnostic. In addition, angiography may be performed if CT scanning or MRI findings are inconclusive.
Ultrasonography, excluding EUS, and nuclear medicine studies are of minor significance in the evaluation of esophageal varices.
Limitations of techniques
Although endoscopy is the criterion standard in diagnosing and grading esophageal varices, the anatomy outside of the esophageal mucosa cannot be evaluated with this technique. Therefore, imaging modalities such as CT scanning, MRI, and EUS are also performed for a more complete evaluation.
Barium swallow examination is not a sensitive test, and it must be performed carefully with close attention to the amount of barium used and the degree of esophageal distention. Barium swallow images may help in detecting only 50% of esophageal varices.
On CT scans and MRIs, esophageal varices are difficult to see at times. However, in severe disease, esophageal varices may be prominent. CT scanning and MRI are useful in evaluating other associated abnormalities and adjacent anatomic structures in the abdomen or thorax. On MRIs, surgical clips may create artifacts that obscure portions of the portal venous system. Disadvantages of CT scanning include the possibility of adverse reactions to the contrast agent and an inability to quantitate portal venous flow, which is an advantage of MRI and ultrasonography.